Private Schools

CEO C_15 Menu Survey

OMB Clearance # 0584-XXXX

Expiration Date: XX/XX/20XX

Community Eligibility Option Evaluation

Menu Survey

Attach School ID Label

If you have questions or need assistance, please call
Abt’s toll-free number: 855-759-5752

The Community Eligibility Option Evaluation is being conducted for the:

Food and Nutrition Service

US Department of Agriculture

3101 Park Center Drive

Alexandria, Virginia 22301

By:

Abt Associates Inc.

55 Wheeler Street

Cambridge, Massachusetts 02138

Information provided in this survey will be kept private, to the extent provided by law. No data will be attributed to specific survey respondents. De-identified data from this study will be provided to the Food and Nutrition Service of the U.S Department of Agriculture, and aggregate measures of subgroups of Local Education Agencies (LEAs) may also be provided. Responses to the study will in no way affect your agency’s receipt of funds from USDA’s school meals program. As you may know, the Healthy-Free Kids Act of 2010 (PL 111-296, Section 305) requires cooperation with program research and evaluation by agencies and contractors participating in programs authorized under the Act and the Child Nutrition Act of 1966.

If you have any questions or concerns about your rights as a study participant, call Teresa Doksum. She is the Institutional Review Board Administrator at Abt Associates. Her phone number is 877-520-6835 (toll-free).

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 35 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Food and Nutrition Service, Office of Research and Analysis, 3101 Park Center Drive, Alexandria, Virginia 22302.

OMB Clearance # 0584-XXXX

Expiration Date: XX/XX/20XX

Community Eligibility Option Evaluation

Daily Meal Counts Form—CEO Schools

School Name: _____________________________ Date (1st day of Target Week):__________

Instructions: In the boxes for Reimbursable Lunches and Reimbursable Breakfasts, please write in the number of USDA reimbursable meals served in your school each day of the target week. Do not include meals for which you do not claim reimbursement, for example, second lunches sold to students on an a la carte basis.

Number of Reimbursable Lunches Served

Day of Week	Total
Monday
Tuesday
Wednesday
Thursday
Friday

Number of Reimbursable Breakfasts Served

Day of Week	Total
Monday
Tuesday
Wednesday
Thursday
Friday

OMB Clearance # 0584-XXXX

Expiration Date: XX/XX/20XX

Community Eligibility Option Evaluation

Daily Meal Counts Form—Non-CEO Schools

School Name: _____________________________ Date (1st day of Target Week):__________

Instructions: In the boxes for Reimbursable Lunches and Reimbursable Breakfasts, please write in the number of USDA reimbursable meals served in your school each day of the target week. Please write the number of free meals, reduced-price meals, and full-price meals, as well as the total number of meals. Do not include meals for which you do not claim reimbursement, for example, second lunches sold to students on an a la carte basis.

Number of Reimbursable Lunches Served

Day of Week	Free	Reduced-Price	Full-Price	Total
Monday
Tuesday
Wednesday
Thursday
Friday

Number of Reimbursable Breakfasts Served

Day of Week	Free	Reduced-Price	Full-Price	Total
Monday
Tuesday
Wednesday
Thursday
Friday

OMB Clearance # 0584-XXXX

Expiration Date: XX/XX/20XX

Community Eligibility Option Evaluation

Reimbursable Food Form: Breakfast

School Name: _____________________________________________ Day of the Week: □ Mon □ Tue □ Wed □ Thu □ Fri

A.	B.	C.	D.	E.	F.	G.	H.
Food Item	Portion Size (include units)	Number of Servings Planned (reimbursable only)	Manufacturer/Brand Name and Product Code (if applicable)	Food Description When describing food, include information about type, form, flavor, and fat content	USDA Commodity?	Recipe?	ABT USE ONLY
MILK (Note: if more than one size is available, list in blank spaces)
White, 1%	fl oz.
White, fat-free/skim	fl oz.
Chocolate fat-free/skim	fl oz.
Flavored fat-free/skim	fl oz.			Specify flavor:
FRUIT (Note: Prelisted entries should be used for fruit that is served as purchased. If anything is added before serving, list as separate item and complete RECIPE FORM)
Apple, fresh					
Banana, fresh
Blueberries	cup			 Fresh  Frozen  Sweetened  Unsweetened	
Grapes, fresh
Orange, fresh					
Peaches, canned	cup			 Heavy syrup  Light syrup  Extra light syrup  Juice  Water	
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JUICES (Note: prelisted entries should be used only for 100% fruit and vegetable juice. List fruit drinks under “Other Menu Items” section.)
Orange juice	fl oz.			 Vitamin C added  Calcium added	
Apple juice	fl oz.			 Vitamin C added  Calcium added
	fl oz.			 Vitamin C added  Calcium added	
	fl oz.			 Vitamin C added  Calcium added	
	fl oz.			 Vitamin C added  Calcium added	
	fl oz.			 Vitamin C added  Calcium added	
	fl oz.			 Vitamin C added  Calcium added	
COLD CEREALS
Cheerios – Plain	oz.
Cheerios – Honey Nut	oz.
Cinnamon Toast Crunch	oz.
Golden Grahams	oz.
Trix	oz.
Special K	oz.
Frosted Flakes	oz.
Lucky Charms	oz.
	oz.
	oz.
	oz.
	oz.
	oz.
	oz.
	oz.
	oz.
HOT CEREALS (Note: if prepared with fat and/or milk, complete RECIPE FORM)
Cream of Wheat	oz.			 Instant  Quick  Reg		
Grits	oz.			 Instant  Quick  Reg		
Oatmeal	oz.			 Instant  Quick  Reg		
	oz.					
	oz.					
OTHER BREADS AND GRAINS OFFERED SEPARATELY
Bagel	oz.			Type:  Whole grain
Biscuit	oz.			Type:  Whole grain		
Doughnut	oz.			Type:  Icing/glaze  No icing/glaze
English muffin	oz.			Type:  Whole grain  Margarine  Butter		
Granola/cereal bar	oz.			Specify type(s):
Muffin	oz.			Specify type(s):		
Pancake	oz.			Weight of each:		
Roll, cinnamon	oz.			 Icing  No icing		
Toast	oz.			Type:  Whole grain  Margarine  Butter		
Toaster pastry	oz.			 Icing  No icing
Waffle/waffle sticks				Weight of each/stick: oz.		
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MEAT AND MEAT ALTERNATES OFFERED SEPARATELY
Bacon	slices			 Pork  Turkey
Eggs				 Boiled  Fried  Scrambled If prepared with fat and/or milk, complete RECIPE FORM		
Ham	oz.			 Pork  Turkey	
Sausage	oz.			 Pork  Turkey  Beef
Yogurt	oz.			Specify flavors:  Regular  Low fat  Fat free  Low-cal sweetener
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COMBINATION BREAD/MEAT ITEMS
Entrée bar	Self-serve		List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM
Breakfast burrito	oz.			Specify fillings:		
Cheese sandwich, toasted	1 sandwich			 Bagel  English muffin  White bread  Whole wheat bread		
Egg sandwich	1 sandwich			 Cheese  Sausage □Ham  Bacon  Other:  Bagel  English muffin  White bread  Whole wheat bread		
French toast						
French toast sticks	ea.			Weight of each stick: oz.
Pancake/sausage on a stick	oz.			Weight of each stick: oz.
Breakfast pizza	oz.			Specify toppings:		
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COMBINATION BREAD/MEAT ITEMS (continued)
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CONDIMENTS (Include size if single-serve item)
Self-Serve Bar	Self-serve		List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM
Butter
Cream cheese				 Reg  Low fat  Fat-free
Gravy				 Reg  Low fat  Fat-free		
Jelly
Ketchup
Margarine
Salsa						
Syrup				 Reg  Low sugar  Sugar-free		
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OTHER MENU ITEMS
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OMB Clearance # 0584-XXXX

Expiration Date: XX/XX/20XX

Community Eligibility Option Evaluation

Reimbursable Food Form: Lunch

School Name: _____________________________________________ Day of the Week: □ Mon □ Tue □ Wed □ Thu □ Fri

A.	B.	C.	D.	E.	F.	G.	H.
Food Item	Portion Size (include units)	Number of Servings Planned (reimbursable only)	Manufacturer/ Brand Name and Product Code (if applicable)	Food Description When describing food, include information about type, form, flavor, and fat content	USDA Commodity?	Recipe?	ABT USE ONLY
MILK (Note: if more than one size is available, list in blank spaces)
White, 1%	fl oz.
White, fat-free/skim	fl oz.
Chocolate fat-free/skim	fl oz.
Flavored fat-free/skim	fl oz.			Specify flavor:
FRUIT (Note: Prelisted entries should be used for fruit that is served as packaged. If anything is added before serving, list as separate item and complete RECIPE FORM)
Apple, fresh					
Banana, fresh
Grapes, fresh
Orange, fresh					
Pears, fresh					
Applesauce, canned	cup			 Sweetened  Unsweetened	
Fruit cocktail, canned	cup			 Heavy syrup  Light syrup  Extra light syrup  Juice  Water	
Peaches, canned	cup			 Heavy syrup  Light syrup  Extra light syrup  Juice  Water	
Pears, canned	cup			 Heavy syrup  Light syrup  Extra light syrup  Juice  Water	
Pineapple, canned	cup			 Heavy syrup  Light syrup  Extra light syrup  Juice  Water
FRUIT (continued)						
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JUICES (Note: prelisted entries should be used only for 100% fruit and vegetable juice. Fruit drinks are included in “Desserts, Drinks, and Snacks” section.)
Orange juice	fl oz.			 Vitamin C added  Calcium added	
Apple juice	fl oz.			 Vitamin C added  Calcium added
Frozen juice cup / bar	fl oz.			 Vitamin C added  Calcium added
	fl oz.			 Vitamin C added  Calcium added	
	fl oz.			 Vitamin C added  Calcium added	
	fl oz.			 Vitamin C added  Calcium added	
	fl oz.			 Vitamin C added  Calcium added	
VEGETABLES
Beans, green	cup			 Fresh  Frozen  Canned  Seasoning/fat added ↘ Specify		
Broccoli	cup			 Fresh  Frozen  Canned  Seasoning/fat added ↘ Specify		
Carrots, cooked	cup			 Fresh  Frozen  Canned  Seasoning/fat added ↘ Specify		
Corn, kernels	cup			 Fresh  Frozen  Canned  Seasoning/fat added ↘ Specify		
Peas, green	cup			 Fresh  Frozen  Canned  Seasoning/fat added ↘ Specify		
VEGETABLES (continued)
Potatoes, whipped or mashed	cup			 From fresh If prepared with fat and/or milk, use RECIPE FORM		
French fries	oz.			 Oven baked  Deep fried		
Tater tots or shapes	oz.			 Oven baked  Deep fried		
Salad bar (non-entrée or small portion)	Self-serve		List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM
Salad, tossed	cup			List dressing as separate item or complete RECIPE FORM		
Carrot sticks				If offered, list dip as separate item(s) or complete RECIPE FORM		
Celery sticks						
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ENTREES OTHER THAN SANDWICHES OR SELF-SERVE BARS (Exclude specialty lunches, such as those offered only to children with certain allergies or the inability to pay.)
Pizza, cheese	oz.			 Thin crust  Thick crust Stuffed crust  Whole grain crust		
Pizza, French bread	oz.			 Whole grain crust		
Pizza, pepperoni	oz.			 Thin crust  Thick crust Stuffed crust  Whole grain crust		
Pizza, sausage	oz.			 Thin crust  Thick crust Stuffed crust  Whole grain crust		
Pizza, other specify	oz.			 Thin crust  Thick crust Stuffed crust  Whole grain crust		
Pizza, other specify	oz.			 Thin crust  Thick crust Stuffed crust  Whole grain crust		
Chicken patties (not sandwich)	oz.			 Breaded  Oven baked  Deep fried
ENTREES OTHER THAN SANDWICHES OR SELF-SERVE BARS (continued)
Chicken piece(s) (specify part) _______________ (specify part) _______________				 Breaded  With skin  Oven baked  Deep fried		
Chicken nuggets	ea.			 Oven baked  Deep fried Weight of each nugget: oz.
Turkey, slice	oz.				
Ham, slice	oz.			 Pork  Turkey	
Corndog	oz.			 All beef  Pork & beef  Chicken or turkey
Burrito	oz.			Specify fillings:		
Taco				 Hard shell  Soft tortilla Specify filling:		
Spaghetti with meat sauce	cup					
Chef’s salad	1 salad					
Yogurt (as meat alternate)	oz.			Specify flavors:  Regular  Low fat  Fat free  Low-cal sweetener
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SANDWICHES & BURGERS: Describe contents of each sandwich in space at right.			For each sandwich type, complete a Recipe Form or record information for sandwich below including type and weight of bread; type and amount of filling; type and amount of any additions. Provide recipe if needed, such as for Tuna Salad. See Instruction Manual for examples.
Sandwich/deli bar	Self-serve		List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM (See Instruction Manual for examples.)
Hamburger	1 sandwich					
Cheeseburger	1 sandwich					
Hot dog	1 sandwich					
Italian sub	1 sandwich					
Chicken filet or breast (not breaded)	1 sandwich					
Chicken patty (breaded)	1 sandwich					
Rib, barbeque	1 sandwich					
Turkey	1 sandwich					
Tuna salad	1 sandwich					
Cheese, grilled	1 sandwich					
Ham and cheese	1 sandwich					
Peanut butter (or almond, sesame, or sun butter) & jelly	1 sandwich		Do not record sandwich if not available to ALL students.			
	1 sandwich					
	1 sandwich					
	1 sandwich					
	1 sandwich					
SELF-SERVE ENTRÉE BARS
Entrée salad bar (or large portion)	Self-serve		List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM
Potato bar	Self-serve		List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM
Nacho/taco bar	Self-serve		List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM
	Self-serve		List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM
	Self-serve		List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM
	Self-serve		List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM
BREADS AND GRAINS OFFERED SEPARATELY
Biscuit	oz.			Type:  Whole grain		
Bread, plain	oz.			Type:  Whole grain
Bread, buttered	oz.			Type:  Whole grain Margarine  Butter
Breadstick	oz.			Type:  Whole grain		
Cornbread	oz.					
Crackers	ea.			Type:  Whole grain
Rice	cup			Type:  Brown		
Roll	oz.			Type:  Whole grain		
Pasta	cup			Type:  Whole grain		
Pretzels	oz.			 Soft  Hard  Whole grain		
Tortilla	oz.			Type:  Whole grain		
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DESSERTS, DRINKS, AND SNACKS OFFERED AS PART OF THE REIMBURSABLE MEAL
Brownie						
Cake				Specify type:		
Cookie	oz.			Specify type:		
Fruit drink	fl oz.			Specify type: Specify % juice content:
Gelatin, plain	cup
DESSERTS, DRINKS, AND SNACKS OFFERED AS PART OF THE REIMBURSABLE MEAL (continued)
Gelatin, with fruit	cup					
Potato chips	oz.			Specify type:
Yogurt	oz.			Specify flavors:  Regular  Low fat  Fat free  Low-cal sweetener
Pudding	oz.			Flavor:		
Ice cream / ice milk	fl oz.			 Regular  Low fat  Fat free		
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SALAD DRESSINGS
French dressing				 Regular  Low fat  Fat free		
Italian dressing				 Regular  Low fat  Fat free		
Ranch dressing				 Regular  Low fat  Fat free		
				 Regular  Low fat  Fat free		
				 Regular  Low fat  Fat free		
				 Regular  Low fat  Fat free		
				 Regular  Low fat  Fat free		
OTHER CONDIMENTS (Include size of packet if single-serve. Write “Self -Serve” if students can choose the portion.)
Self-serve bar	Self-Serve		List all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM (See Instruction Manual for examples.)
Barbeque sauce						
Butter
Cream cheese				 Regular  Low fat  Fat free
Gravy				 Regular  Low fat  Fat free		
Honey
Ketchup
Margarine
Mayonnaise				 Regular  Low fat  Fat free
Mustard
Tartar sauce				 Regular  Low fat  Fat free		
OTHER CONDIMENTS (Continued)
Peppers, jalapeno
Pickles, relish
Pickles, slices
Ranch dip				 Regular  Low fat  Fat free		
Salsa						
Sour cream				 Regular  Low fat  Fat free
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OTHER MENU ITEMS
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OMB Clearance # 0584-XXXX

Expiration Date: XX/XX/20XX

Self-Serve and Made-to-Order Bar Form

Meal (Circle one): Breakfast Lunch

Name of Bar: ___________________________________ Day(s): 1 Mon 2 Tue 3 Wed 4 Thu 5 Fri

A.	B.	C.	D.	E.	F.	G.
Food Item	Portion size (If pre-portioned, include units)	Manufacturer/Brand Name & Product Code (if applicable)	Include the following information: Type, Form, Flavor, Fat content (See instruction manual for examples of each) Food Description	USDA Commodity?	Recipe? *	ABT USE ONLY
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*For each recipe, record recipe details on a Recipe Form

OMB Clearance # 0584-XXXX

Expiration Date: XX/XX/20XX

Community Eligibility Option Evaluation

Recipe Forms

The Community Eligibility Option Evaluation is being conducted for the:

Food and Nutrition Service

US Department of Agriculture

3101 Park Center Drive

Alexandria, Virginia 22301

By:

Abt Associates Inc.

55 Wheeler Street

Cambridge, Massachusetts 02138

Recipe Form (Side 1)

Recipe/Food name: ______________________________ Size of one serving (include units): ________________

Meal: 1  Breakfast 2  Lunch This recipe makes __________ servings

Day(s): 1  Mon 2  Tue 3  Wed 4  Thu 5  Fri  Recipe Attached: (Please fill out Side 2)

A.	B.	C.	D.	E.	F.	G.
Ingredient Name	Amount in Recipe (Include units)	Manufacturer/Brand Name and Product Code	Include the following information: Type, Form, Flavor, Fat content (See instruction manual for examples of each) Ingredient Description	USDA Commodity?	Recipe?	ABT USE ONLY
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Recipe Form (Side 2)

Preparation Information

Please check () the boxes below to describe the procedures used in preparing this recipe.

1. If recipe was cooked, what cooking method did you use? (check all that apply)

1  Bake/roast

2  Oven heat

3  Microwave/warmer

4  Broil/grill

5  Pan fry/sauté 10  Floured 11  Battered

6  Deep fry 12  Floured 13  Battered

7  Boil

8  Steam

9  Other (Specify):

n  Does not apply to recipe

2. If recipe contains meat or poultry, was amount measured raw or cooked?

n  Does not apply to recipe SKIP TO Q.4

1  Raw

2  Cooked

3. If recipe contains meat or poultry, did you . . .

check all that apply	Yes	No	Does not apply to recipe
Trim the visible fat?	1 	0 	n 
Drain fat after cooking?	1 	0 	n 
Remove skin before cooking?	1 	0 	n 

4. If recipe contains noodles, rice, or vegetables, did you add salt to the cooking water?

	Yes	No	Does not apply to recipe
Noodles/pasta or rice	1 	0 	n 
Vegetables	1 	0 	n 

5. If recipe contains canned vegetables or canned fruit, did you drain off all of the liquid?

1  Yes 0  No n  Does not apply to recipe

Comments